The frontal and medial aspects of the thigh pdf - Lower limb

450

CHAPTER 10

The Lower Limb

sciatic nerve

L4 L5 S1 S2 S3

pelvis

sacral plexus

gluteal region

sciatic nerve

hip joint

tibial nerve

common peroneal nerve

back of thigh

semitendinosus

biceps femoris

(long head)

semimembranosus

adductor magnus

(hamstring part)

lower leg

knee joint

gastrocnemius

soleus

plantaris

popliteus

tibialis posterior

flexor digitorum longus

flexor hallucis longus

skin of ankle

ankle joint

sural nerve

sole of foot

medial plantar nerve

adductor hallucis

flexor digitorum brevis

flexor hallucis brevis

first lumbrical

joints

of foot

skin of sole
of foot

lateral plantar nerve

skin of sole

of foot

flexor digitorum accessorius

abductor digiti minimi

flexor digiti minimi brevis

second, third, fourth lumbricals

abductor hallucis

all interossei

FIGURE 10.17

Summary of the origin of the sciatic nerve and the main branches of the tibial nerve.

a branch of the

lateral cutaneous nerve of the thigh,

The

Cutaneous Nerves

The Front and Medial Aspects

of the Thigh

Skin of the Thigh

lumbar plexus (L2 and 3), enters the thigh behind the lateral

the cremaster muscle (see page 222).

small area of skin (Fig. 10.2). The genital branch supplies

behind the middle of the inguinal ligament and supplies a

branch of the lumbar plexus (L1 and 2), enters the thigh

femoral branch of the genitofemoral nerve,

The

skin of the lower lateral quadrant of the buttock (Fig. 10.1).

the lateral aspect of the thigh and knee. It also supplies the

into anterior and posterior branches, it supplies the skin of

end of the inguinal ligament (Fig. 10.2). Having divided

Basic Anatomy

451

artery

arterial supply

femoral arteries

from circumflex

arterial supply

synovial sheath

small branch of obturator artery

obturator artery

transverse acetabular ligament

acetabular labrum

articular surface

synovial membrane

synovial sheath

epiphyseal line

acetabular

acetabulum

synovial membrane

acetabular labrum

capsule

head of femur

fossa

pad of fat

ligament
of head
of femur

ligament of head of femur

from obturator

ligament of head of femur

FIGURE 10.18

Coronal section of the right hip joint

opening in the deep fascia and joins the femoral vein about

thigh. It passes through the lower part of the saphenous

the knee and curves forward around the medial side of the

cia over the medial side of the leg. The vein passes behind

in company with the saphenous nerve in the superficial fas

the medial malleolus (Fig. 10.19). It then ascends

in front of

directly

dorsal venous arch of the foot and passes upward

drains the medial end of the

great saphenous vein

The

of great clinical importance.

saphenous veins and their tributaries (Fig. 10.19). They are

The superficial veins of the leg are the great and small

Superficial Veins

infrapatellar branch of the saphenous nerve (Fig. 10.2).

mediate, and medial cutaneous nerves of the thigh and the

formed from the terminal branches of the lateral, inter

lies in front of the knee and is

patellar plexus

The

the thigh (Fig. 10.2).

supply a variable area of skin on the medial aspect of

nerve

obturator

Branches from the anterior division of the

plexus (Fig. 10.2).

supply the anterior aspect of the thigh and joins the patellar

branch of the femoral nerve, divides into two branches that

intermediate cutaneous nerve of the thigh,

The

and joins the patellar plexus (Fig. 10.2).

the femoral nerve, supplies the medial aspect of the thigh

a branch of

medial cutaneous nerve of the thigh,

The

nal ligament.

and to a small skin area below the medial part of the ingui

ris and adjacent part of the labium majus in the female)

penis and adjacent part of the scrotum (or root of the clito

(Fig. 10.2). It is distributed to the skin of the root of the

(L1), enters the thigh through the superficial inguinal ring

a branch of the lumbar plexus

ilioinguinal nerve,

The

head of the femur

and articular surfaces of the right hip joint and arterial supply of the

(A)

(B).

452

CHAPTER 10

The Lower Limb

perforating vein

saphenous opening

anterior superior

iliac spine

femoral vein

femoral artery

great saphenous vein

accessory vein

dorsal venous arch

medial malleolus

small
saphenous
vein

superficial external pudendal vein

pubic tubercle

superficial epigastric vein

superficial circumflex iliac vein

popliteal vein

lateral
malleolus

muscle

superficial
fascia

saphenous vein

deep fascia

"venous pump"

venae comitantes

skin

great saphenous vein

FIGURE 10.19

ance of the valved perforating veins in the “venous pump.”

Superficial veins of the right lower limb. Note the import

is described on page 487.

small saphenous vein

The

up at the saphenous opening.

joins the main vein about the middle of the thigh or higher

usually

accessory vein,

An additional vein, known as the

artery found in this region.

veins correspond with the three branches of the femoral

These

superficial external pudendal vein.

vein,

superficial epigastric

superficial circumflex iliac vein,

variable in size and arrangement (Figs. 10.3 and 10.19): the

saphenous vein usually receives three tributaries that are

At the saphenous opening in the deep fascia, the great

along the medial side of the calf (Fig. 10.19).

connect the great saphenous vein with the deep veins

veins

perforating

branches that pass behind the knee. Several

and is connected to the small saphenous vein by one or two

The great saphenous vein possesses numerous valves

1.5 in. (4 cm) below and lateral to the pubic tubercle (Figs.
10.3 and 10.19).

the

and the

454

CHAPTER 10

The Lower Limb

medial malleolus of tibia

edge of saphenous

opening in deep

fascia

femoral artery

femoral vein

great saphenous
vein

saphenous nerve

great saphenous vein

saphenous nerve

great saphenous vein

pubic
tubercle

anterior superior
iliac spine

FIGURE 10.20

Great saphenous vein cutdown.

of the group receive superficial lymph vessels from the anterior

inguinal ligament (Figs. 10.3 and 10.4). The medial members

lies just below and parallel to the

horizontal group

The

a vertical group (Figs. 10.3 and 10.4).

inguinal ligament and can be divided into a horizontal and

The superficial nodes lie in the superficial fascia below the

Superficial Inguinal Lymph Nodes

deep groups.

The inguinal lymph nodes are divided into superficial and

Inguinal Lymph Nodes

below and lateral to the pubic tubercle.

At the groin. The great saphenous vein drains into the femoral vein two fingerbreadths

At the ankle. The great saphenous vein is constantly found in front of the

A, B.

medial malleolus of the tibia. C, D.

abdominal wall below the level of the umbilicus and from the
perineum (Fig. 10.4). The lymph vessels from the urethra,
the external genitalia of both sexes (but not the testes), and

is attached to the deep fascia (fascia lata) about a

anterior abdominal wall extends into the thigh and

of the

membranous layer of the superficial fascia

The

the external iliac artery (see Fig. 5.76).

passing through the femoral canal to lymph nodes along

the efferent vessels from these nodes enter the abdomen by

lie along the medial side of the femoral vein (Fig. 10.21);

The deep nodes are located beneath the deep fascia and

Deep Inguinal Lymph Nodes

cia and join the deep inguinal nodes.

nodes pass through the saphenous opening in the deep fas

The efferent lymph vessels from the superficial inguinal

lymph vessels of the lower limb (Figs. 10.3 and 10.4).

great saphenous vein and receives most of the superficial

lies along the terminal part of the

vertical group

The

from the back below the level of the iliac crests (Fig. 10.4).

lateral members of the group receive superficial lymph vessels

the lower half of the anal canal are drained by this route. The

Superficial Fascia of the Thigh

Lymphatics of the Lower Limb

node caused by lymphatic spread of pathogenic organisms

The superficial and deep inguinal lymph nodes not only drain

all the lymph from the lower limb, but also drain lymph from

the skin and superficial fascia of the anterior and posterior

abdominal walls below the level of the umbilicus; lymph from

the external genitalia and the mucous membrane of the lower

half of the anal canal also drains into these nodes. Remember

the large distances the lymph has had to travel in some

instances before it reaches the inguinal nodes. For example,

a patient may present with an enlarged, painful inguinal lymph

that entered the body through a small scratch on the under-

surface of the big toe.

C L I N I C A L N O T E S

Basic Anatomy

455

inguinal ligament

femoral nerve

iliopsoas

femoral artery

femoral sheath femoral vein

femoral canal

pubic tubercle

lymphatic vessel

pectineus

external iliac artery and vein

femoral sheath

femoral artery

lymphatic vessel

femoral ring

femoral canal

internal oblique

external oblique

inguinal ligament

membranous layer

fatty layer

superficial fascia

deep fascia

lymph node

femoral canal

pubis

fascia

iliaca

peritoneum

extraperitoneal fat

fascia transversalis

transversus

FIGURE 10.21

Right femoral sheath and its contents.

fingerbreadth below the inguinal ligament (Figs. 10.3 and

The deep fascia encloses the thigh like a trouser leg

over the lower limb without interruption (Fig. 10.21).

abdominal wall extends into the thigh and continues down

on the anterior

fatty layer of the superficial fascia

The

described in Chapter 4.

extravasation of urine after a rupture of the urethra is fully

10.21). The importance of this fact in connection with

Deep Fascia of the Thigh (Fascia Lata)

(Fig.

r end is attached to the pelvis and

10.22) and at its uppe

are described in Table 10.2.

The muscles are seen in Figures 10.6, 10.23, and 10.24 and

of the Thigh

Muscles of the Anterior Fascial Compartment

Femoral nerve

Nerve supply:

Femoral artery

Blood supply:

ceps femoris

Sartorius, iliacus, psoas, pectineus, and quadri

Muscles:

compartments are anterior, medial, and posterior in position.

partments, each having muscles, nerves, and arteries. The

10.22). By this means, the thigh is divided into three com

cial sheath of the thigh to the linea aspera of the femur (Fig.

Three fascial septa pass from the inner aspect of the deep fas

cribriform fascia.

tissue called the

The saphenous opening is filled with loose connective

the superior ramus of the pubis.

the femoral vessels, to be attached to the pectineal line of

then curves upward and medially, and then laterally behind

to the femoral vessels (Fig. 10.3). The border of the opening

the lower lateral border of the opening, which lies anterior

falciform margin

and lateral to the pubic tubercle. The

saphenous opening is situated about 1.5 in. (4 cm) below

of the femoral artery, and lymph vessels (Fig. 10.3). The

transmits the great saphenous vein, some small branches

the front of the thigh just below the inguinal ligament. It

is a gap in the deep fascia in

saphenous opening

The

the tensor fasciae latae and the gluteus maximus muscles.

gluteal region, the deep fascia forms sheaths, which enclose

gluteus maximus muscle (see Figs. 10.5 and 10.6). In the

tion of the tensor fasciae latae and the greater part of the

condyle of the tibia. The iliotibial tract receives the inser

attached above to the iliac tubercle and below to the lateral

(Figs. 10.6 and 10.22), which is

iliotibial tract

to form the

the inguinal ligament. On its lateral aspect, it is thickened

Fascial Compartments of the Thigh

Contents of the Anterior Fascial

Compartment of the Thigh

■

456

CHAPTER 10

The Lower Limb

rectus femoris

deep fascia

vastus medialis

nerve to vastus medialis

saphenous nerve

femoral vein

femoral artery

sartorius

great saphenous

vein

adductor longus

gracilis

adductor magnus

semimembranosus

posterior cutaneous nerve of thigh

semitendinosus

biceps femoris

sciatic nerve

iliotibial tract

profunda femoris

artery

vastus lateralis

vastus intermedius

medial

lateral

FIGURE 10.22

Transverse section through the middle of the right thigh as seen from above.

femoral artery femoral nerve psoas inguinal ligament iliacus sartorius

tensor
fasciae
latae
muscular
branches
of femoral
nerve
profunda
femoris
artery
lateral
femoral
circumflex
artery
vastus
lateralis

intermediate
cutaneous
nerve of
the thigh

medial
cutaneous
nerve of
the thigh

rectus
femoris

gracilis

great
saphenous
vein

adductor
longus

pectineus

femoral vein

site of
femoral
canal

FIGURE 10.23

Dissection of the femoral triangle in the left lower limb.

Basic Anatomy

457

iliacus

femoral sheath

obturator externus

adductor brevis

profunda femoris artery

perforating arteries

femoral vein

descending
genicular artery

femoral artery

adductor magnus

posterior division

obturator nerve

anterior division

pectineus

lacunar ligament

femoral ring

femoral vessels

psoas

femoral nerve

adductor longus

FIGURE 10.24

Relationship between the obturator nerve and the adductor muscles in the right lower limb.

Adductor (Subsartorial) Canal

tributaries, and the deep inguinal lymph nodes.

femoral artery and its branches, the femoral vein and its

femoral nerve and its branches, the femoral sheath, the

The femoral triangle contains the terminal part of the

is formed by the skin and fasciae of the thigh.

roof

by the iliopsoas, the pectineus, and the adductor longus. Its

is gutter shaped and formed from lateral to medial

floor

Its

The adductor longus muscle

Medially:

The sartorius muscle

Laterally:

The inguinal ligament

Superiorly:

as follows:

below the inguinal ligament (Fig. 10.6). Its boundaries are

ated in the upper part of the medial aspect of the thigh just

The femoral triangle is a triangular depressed area situ

Femoral Triangle

The rectus femoris muscle also flexes the hip joint.

the quadriceps muscle greatly strengthens the knee joint.

during contraction of the quadriceps muscle. The tone of

zontal and prevent the patella from being pulled laterally

lowest muscle fibers of the vastus medialis are almost hori

join the capsule of the knee joint and strengthen it. The

which

retinacula,

eralis and vastus medialis form bands, or

knee joint. Some of the tendinous fibers of the vastus lat

10.25). Together, they provide a powerful extensor of the

mentum patellae, is attached to the tibial tuberosity (Fig.

vastus medialis, is inserted into the patella and, via the liga

femoris, the vastus intermedius, the vastus lateralis, and the

The quadriceps femoris muscle, consisting of the rectus

(Quadriceps Mechanism)

Action of Quadriceps Femoris Muscle

Note the following:

■

The adductor canal is an intermuscular cleft situated on the

terminal part of the obturator nerve.

saphenous nerve, the nerve to the vastus medialis, and the

oral artery, the femoral vein, the deep lymph vessels, the

The adductor canal contains the terminal part of the fem

is formed by the vastus medialis.

lateral wall

The

and magnus.

is formed by the adductor longus

posterior wall

The

cle and fascia.

is formed by the sartorius mus

anteromedial wall

The

and a lateral wall.

is triangular, having an anteromedial wall, a posterior wall,

at the opening in the adductor magnus. In cross section, it

above at the apex of the femoral triangle and ends below

sartorius muscle (Figs. 10.6 and 10.22). It commences

medial aspect of the middle third of the thigh beneath the

■

458

CHAPTER 10

The Lower Limb

Vastus

Vastus medialis

Vastus lateralis

bodies, and intervertebral

Transverse processes,

Muscle

Origin

Insertion

Nerve
Supply

Nerve Root

Action

Sartorius

Anterior superior iliac

spine

Upper medial

surface of

shaft of tibia

Femoral

nerve

L2, 3

Flexes, abducts,

laterally rotates

thigh at hip

joint; flexes and

medially rotates

leg at knee joint

Iliacus

Iliac fossa of hip bone

With psoas into

lesser trochanter

of femur

Femoral

nerve

L2, 3

Flexes thigh on

trunk; if thigh is

fixed, it flexes the

trunk on the thigh

as in sitting up

from lying down

Psoas

discs of the 12th

thoracic and five lumbar

vertebrae

With iliacus into

lesser trochanter

of femur

Lumbar

plexus

L1, 2, 3

Flexes thigh on

trunk; if thigh is

fixed, it flexes the

trunk on thigh as

in sitting up from

lying down

Pectineus

Superior ramus of pubis

Upper end of linea

aspera of shaft of

femur

Femoral

nerve

L2, 3

Flexes and adducts

thigh at hip joint

Quadriceps

femoris

Rectus femoris

Straight head: anterior

inferior iliac spine

Reflected head: ilium

above acetabulum

Quadriceps tendon

into patella, then

via ligamentum

patellae into

tubercle of tibia

Femoral

nerve

L2, 3, 4

Extension of leg at

knee joint; flexes

thigh at hip joint

Upper end and shaft of

femur

Quadriceps tendon

into patella, then

via ligamentum

patellae into

tubercle of tibia

Femoral

nerve

L2, 3, 4

Extension of leg at

knee joint

Upper end and shaft of

femur

Quadriceps tendon

into patella, then

via ligamentum

patellae into

tubercle of tibia

Femoral

nerve

L2, 3, 4

Extension of leg

at knee joint;

stabilizes patella

intermedius

Anterior and lateral

surfaces of shaft of

femur

Quadriceps tendon

into patella, then

via ligamentum

patellae into

tubercle of tibia

Femoral

nerve

L2, 3, 4

Extension of leg

at knee joint;

articularis genus

retracts synovial

membrane

The predominant nerve root supply is indicated by boldface type.

Muscles of the Anterior Fascial Compartment of the Thigh

T A B L E 1 0 . 2

Basic Anatomy

459

rectus femoris

retinaculum

muscular fibers of
vastusmedialis

vastus lateralis

large lateral
femoral condyle

retinaculum

ligamentum patellae

fibula

tuberosity of tibia

semitendinosus

gracilis

sartorius

patella

vastus medialis

FIGURE 10.25

The quadriceps femoris mechanism. The lateral and upward pull of the powerful rectus femoris and the vastus

lateral condyle of the femur, which projects forward.

lateralis muscles on the patella is counteracted by the lowest horizontal muscular fibers of the vastus medialis and the large

Quadriceps Femoris as a Knee Joint Stabilizer

knee joint when the quadriceps femoris muscle is actively

This can occur when a sudden flexing force is applied to the

proximally, leaving a gap that may be palpable on the anterior

can be tested by measuring the circumference of each thigh a

The quadriceps femoris is a most important extensor muscle for

the knee joint. Its tone greatly strengthens the joint; therefore,

this muscle mass Vmust be carefully examined when disease of

the knee joint is suspected. Both thighs should be examined, and

the size, consistency, and strength of the quadriceps muscles

should be tested. Reduction in size caused by muscle atrophy

fixed distance above the superior border of the patella.

The vastus medialis muscle extends farther distally than the

vastus lateralis. Remember that the vastus medialis is the first

part of the quadriceps muscle to atrophy in knee joint disease

and the last to recover.

Rupture of the Rectus Femoris

The rectus femoris muscle can rupture in sudden violent exten-

sion movements of the knee joint. The muscle belly retracts

surface of the thigh. In complete rupture of the muscle, surgical

repair is indicated.

Rupture of the Ligamentum Patellae

contracting

C L I N I C A L N O T E S

460

CHAPTER 10

sheath surrounds the femoral vessels and lymphatics for

versalis, and its posterior wall with the fascia iliaca. The

anterior wall is continuous above with the fascia trans

envelope lining the abdominal walls (see page XXX). Its

is a downward protrusion into the thigh of the fascial

The femoral sheath (Figs. 10.3, 10.6, 10.21, and 10.24)

Femoral Sheath

The Lower Limb

about 1 in. (2.5 cm) below the inguinal ligament. The

partment

medial com

by a fibrous septum and occupy the most

vessels, as they leave the thigh, are separated from the vein

The lymph

intermediate compartment.

and occupies the

medial side and is separated from it by a fibrous septum

as it leaves the thigh, lies on its

femoral vein,

sheath. The

of the

lateral compartment

nal ligament, occupies the

as it enters the thigh beneath the ingui

femoral artery,

(Fig. 10.21).

femoral septum,

The

femoral ring.

long, and its upper opening is called the

the lymph vessels (Fig. 10.21). It is about 0.5 in. (1.3 cm)

is the small medial compartment for

femoral canal

The

which is a condensation of

eritoneal

extrap

tissue, closes the ring. The femoral canal contains fatty

connective tissue, all the efferent lymph vessels from the

described below.

and is

femoral hernia

it. Such a condition is known as a

the femoral canal, pushing the femoral septum before

men. A protrusion of peritoneum could be forced down

this site that forms a potentially weak area in the abdo

not adherent to the walls of the small lymph vessels; it is

sheath that forms the medially located femoral canal is

adventitia of these vessels. The part of the femoral

blood vessels and inferiorly blends with the tunica

The femoral sheath is adherent to the walls of the

lymph nodes.

deep inguinal lymph nodes, and one of the deep inguinal

The femoral ring (Fig. 10.21) has the following important

relations: anteriorly, the inguinal ligament;

iorly, the

poster

The lower end of the canal is normally closed by

ment; and laterally, the femoral vein.

superior ramus of the pubis; medially, the lacunar liga-

the adherence of its medial wall to the tunica adventitia of

the deep fascia of the thigh (Fig. 10.3).

the femoral vein. It lies close to the saphenous opening in

Femoral Sheath and Femoral Hernia

ral vessels and lymphatic vessels for about 1 in. (2.5 cm) below

thigh of the fascial lining of the abdomen. It surrounds the femo

The hernial sac descends through the femoral canal within the

femoral sheath.

The femoral sheath is a prolongation downward into the

the inguinal ligament (see Fig. 10.21). The femoral artery, as it

enters the thigh below the inguinal ligament, occupies the lateral

compartment of the sheath. The femoral vein, which lies on its

medial side and is separated from it by a fibrous septum, occu-

pies the intermediate compartment. The lymphatics, which are

separated from the vein by a fibrous septum, occupy the most

medial compartment.

The femoral canal, the compartment for the lymphatic ves-

sels, occupies the medial part of the sheath. It is about 0.5 in.

(1.3 cm) long, and its upper opening is referred to as the

other anatomic structures close to the inguinal ligament. For

hernia, it is important to consider diseases that may involve

When considering the differential diagnosis of a femoral

A femoral hernia is a dangerous condition and should always be

(strangulated hernia).

ring, seriously impairing its blood supply

neck, and its blood vessels may be compressed by the femoral

strains or coughs, a piece of bowel may be forced through the

Furthermore, after the patient

abdominal viscus has passed through the neck into the body of

structures, the neck of the sac is unable to expand. Once an

and laterally to the femoral vein. Because of these anatomic

pubis, medially to the sharp free edge of the lacunar ligament,

teriorly to the pectineal ligament and the superior ramus of the

ring. The ring is related anteriorly to the inguinal ligament, pos

tubercle. The neck of the sac is narrow and lies at the femoral

an inguinal hernia, which lies above and medial to the pubic

(see page 145). This serves to distinguish it from

below and lateral to the

the thigh deep to the deep fascia (see page 143). With further

femoral canal, it expands to form a swelling in the upper part of

femoral

ring. The femoral septum, which is a condensation of extraperi-

toneal tissue, plugs the opening of the femoral ring.

A femoral hernia is more common in women than in men

(possibly because of their wider pelvis and femoral canal). The

hernial sac passes down the femoral canal, pushing the femo-

ral septum before it. On escaping through the lower end of the

expansion, the hernial sac may turn upward to cross the anterior

surface of the inguinal ligament.

The neck of the sac always lies

pubic tubercle

the sac, it may be difficult to push it up and return it to the abdom-

inal cavity (irreducible hernia).

treated surgically.

example:

■

Inguinal canal: The swelling of an inguinal hernia lies above

the medial end of the inguinal ligament. Should the hernial

sac emerge through the superficial inguinal ring to start its

descent into the scrotum, the swelling will lie above and me-

dial to the pubic tubercle. The sac of a femoral hernia lies

below and lateral to the pubic tubercle.

■

Superficial inguinal lymph nodes: Usually, more than one

lymph node is enlarged. In patients with inflammation of the

nodes (lymphadenitis), carefully examine the entire area of

the body that drains its lymph into these nodes. A small, un-

noticed skin abrasion may be found. Never forget the mucous

membrane of the lower half of the anal canal—it may have an

undiscovered carcinoma.

C L I N I C A L N O T E S

(continued)

Basic Anatomy

461

■

lateral femoral

medial

its origin, it gives off the

fourth perforating artery.

It ends by becoming the

partment of the thigh (Figs. 10.23, 10.24, and 10.27).

the femoral vessels and enters the medial fascial com

(Figs. 10.6, 10.23, and 10.26). It passes medially behind

artery about 1.5 in. (4 cm) below the inguinal ligament

branch that arises from the lateral side of the femoral

is a large and important

profunda femoris artery

The

majus).

medially and supplies the skin of the scrotum (or labium

(Fig. 10.6) runs

deep external pudendal artery

The

scrotum (or labium majus).

small branch that runs medially to supply the skin of the

(Fig. 10.3) is a

superficial external pudendal artery

The

the umbilicus (Fig. 10.3).

crosses the inguinal ligament and runs to the region of

is a small branch that

superficial epigastric artery

The

spine (Fig. 10.3).

that runs up to the region of the anterior superior iliac

is a small branch

superficial circumflex iliac artery

The

Branches

(Fig. 10.6).

The femoral nerve and its branches

Laterally:

part of its course (Figs. 10.6 and 10.23).

It is related to the femoral vein in the upper

Medially:

the artery and the adductor longus.

longus (Fig. 10.6). The femoral vein intervenes between

it from the hip joint, the pectineus, and the adductor

The artery lies on the psoas, which separates

Posteriorly:

course, it passes behind the sartorius muscle (Fig. 10.6).

and is covered by skin and fascia. In the lower part of its

In the upper part of its course, it is superficial

Anteriorly:

Relations

popliteal artery (Fig. 10.24).

tor magnus muscle by entering the popliteal space as the

tubercle of the femur and ends at the opening in the adduc

limb. It descends almost vertically toward the adductor

The femoral artery is the main arterial supply to the lower

the anterior superior iliac spine and the symphysis pubis.

(Figs. 10.6, 10.23, and 10.26). Here, it lies midway between

nal ligament, as a continuation of the external iliac artery

The femoral artery enters the thigh from behind the ingui

Femoral Artery

Compartment of the Thigh

Blood Supply of the Anterior Fascial

crease in size when the patient is asked to cough. (Elevated

part of the great saphenous vein, a

■

Great saphenous vein: A localized dilatation of the terminal

saphenous varix, can

cause confusion, especially because a hernia and a varix in-

intra-abdominal pressure drives the blood downward.) The

presence of varicose veins elsewhere in the leg should help

in the diagnosis.

■

Psoas sheath: Tuberculous infection of a lumbar vertebra can

result in the extravasation of pus down the psoas sheath into

the thigh. The presence of a swelling above and below the

inguinal ligament, together with clinical signs and symptoms

referred to the vertebral column, should make the diagnosis

obvious.

■

Femoral artery: An expansile swelling lying along the course

of the femoral artery that fluctuates in time with the pulse

rate should make the diagnosis of aneurysm of the femoral
artery certain.

■

and

circumflex arteries,

that arises from the femoral artery near its termination

is a small branch

descending genicular artery

The

(Fig. 10.27).

three perforating arteries

and during its course it gives off

■

(Fig. 10.24). It assists in supplying the knee joint.

external iliac artery

moral artery

circumflex artery

medial femoral

moral artery

moris artery

perforating

popliteal arte

posterior tibial artery

peroneal arte

arcuate artery

artery

anterior tibial

circumflex artery

profunda artery

inguinal ligament

lateral femoral

dorsalis pedis

branches
of profunda
fe

FIGURE 10.26

Major arteries of the lower limb.

462

CHAPTER 10

The Lower Limb

obturator artery

obturator nerve

anterior division

posterior division

obturator internus

obturator membrane

obturator externus

quadratus femoris

medial femoral circumflex artery

perforating arteries

posterior

adductor magnus

articular branch to knee joint

cutaneous branch

adductor brevis

adductor longus

profunda femoris artery

pectineus

femoral artery

superior ramus of pubis

pubofemoral ligament

divisions of obturator nerve

obturator externus

iliofemoral ligament

FIGURE 10.27

Obturator externus muscle

tomosis between the perforating arteries and the medial femoral circumflex artery.

courses taken by the obturator nerve and its divisions and the profunda femoris artery and its branches. Note also the anas

and vertical section of the medial compartment of the thigh

(A)

(B). Note the

Femoral Artery Catheterization

passed into the inferior mesenteric, superior mesenteric,

A long, fine catheter can be inserted into the femoral artery

as it descends through the femoral triangle. The catheter is

guided under fluoroscopic view along the external and com-

mon iliac arteries into the aorta. The catheter can then be

celiac, or renal arteries. Contrast medium can then be injected

into the artery under examination and a permanent record

obtained by taking a radiograph. Pressure records can also be

obtained by guiding the catheter through the aortic valve into

the left ventricle.

C L I N I C A L N O T E S

Femoral Vein

the thigh, lying at first on the lateral side of the artery, then

popliteal vein (Figs. 10.23 and 10.24). It ascends through

opening in the adductor magnus as a continuation of the

The femoral vein enters the thigh by passing through the

Femoral Vein Catheterization

tionship to the medial side of the femoral artery just below the

large vein is needed. The femoral vein has a constant rela

Femoral vein catheterization is used when rapid access to a

inguinal ligament and is easily cannulated. However, because

of the high incidence of thrombosis with the possibility of fatal

pulmonary embolism, the catheter should be removed once

the patient is stabilized.

Anatomy of the Procedure
1.

The skin of the thigh below the inguinal ligament is sup-

plied by the genitofemoral nerve; this nerve is blocked with

a local anesthetic.

The femoral pulse is palpated midway between the ante-

rior superior iliac spine and the symphysis pubis, and the

femoral vein lies immediately medial to it.

At a site about two fingerbreadths below the inguinal liga-

ment, the needle is inserted into the femoral vein.

C L I N I C A L N O T E S

Basic Anatomy

lateral side of the femoral artery in the femoral triangle,

The profunda femoris is a large artery that arises from the

Profunda Femoris Artery

Compartment of the Thigh

Blood Supply of the Medial Fascial

downward into the popliteal space.

mits the femoral vessels to pass from the adductor canal

the attachment of this muscle to the femur, which per

is a gap in

adductor hiatus

hamstring portions. The

a large, triangular muscle consisting of adductor and

The adductor magnus (Figs. 10.24, 10.27, and 10.29) is

Note the following:

Table 10.3.

Figures 10.22, 10.23, 10.24, and 10.27 and are described in

The muscles of the medial fascial compartment are seen in

of the Thigh

Muscles of the Medial Fascial Compartment

Obturator nerve

Nerve supply:

artery

Profunda femoris artery and obturator

Blood supply:

adductor magnus, and obturator externus

Gracilis, adductor longus, adductor brevis,

Muscles:

supply the knee joint.

the hip joint; the branches to the three vasti muscles also

of the rectus femoris also supplies

muscular branch

The

the region of the ball of the big toe.

along the medial border of the foot, where it terminates in

nous vein. It passes in front of the medial malleolus and

the medial side of the leg in company with the great saphe

dons of sartorius and gracilis (Fig. 10.2). It then runs down

emerges on the medial side of the knee between the ten

ral artery from its lateral to its medial side (Fig. 10.6). It

runs downward and medially and crosses the femo

nerve

saphenous

cular branches to the quadriceps muscle. The

off one cutaneous branch, the saphenous nerve, and mus

The posterior division (Fig. 10.28) gives

Posterior Division

supply the sartorius and the pectineus.

respectively (Figs. 10.2 and 10.6). The muscular branches

the skin of the medial and anterior surfaces of the thigh,

that supply

intermediate cutaneous nerves

thigh

medial cutaneous nerve of the

neous branches are the

off two cutaneous and two muscular branches. The cuta

The anterior division (Fig. 10.28) gives

Anterior Division

Branches

not enter the thigh within the femoral sheath.

Note that the femoral nerve does

of the thigh (Fig. 10.6).

nerve supplies all the muscles of the anterior compartment

dividing into anterior and posterior divisions. The femoral

1.5 in. (4 cm) below the inguinal ligament, it terminates by

the inguinal ligament (Figs. 10.6, 10.21, and 10.23). About

lateral to the femoral artery and the femoral sheath, behind

iliacus. It lies behind the fascia iliaca and enters the thigh

passes downward in the interval between the psoas and

the psoas muscle within the abdomen (see page 222) and

plexus (L2, 3, and 4). It emerges from the lateral border of

The femoral nerve is the largest branch of the lumbar

Femoral Nerve

Compartment of the Thigh

Nerve Supply of the Anterior Fascial

the femoral canal and drain into the external iliac nodes.

inguinal nodes ascend into the abdominal cavity through

the popliteal nodes. The efferent lymph vessels from the deep

vessels alongside the arteries, some having passed through

structures of the lower limb that have ascended in lymph

saphenous opening. They also receive lymph from the deep

lymph vessels that pass through the cribriform fascia of the

receive all the lymph from the superficial inguinal nodes via

rior is usually located in the femoral canal (Fig. 10.21). They

the terminal part of the femoral vein, and the most supe

there are commonly three. They lie along the medial side of

are variable in number, but

deep inguinal lymph nodes

The

Compartment of the Thigh

Lymph Nodes of the Anterior Fascial

external pudendal veins drain into the great saphenous vein.

circumflex iliac vein, the superficial epigastric vein, and the

branches of the femoral artery (Fig. 10.3). The superficial

and veins that correspond to the

great saphenous vein

The tributaries of the femoral vein are the

Tributaries

become the external iliac vein.

femoral sheath and passes behind the inguinal ligament to

It leaves the thigh in the intermediate compartment of the

posterior to it, and finally on its medial side (Fig. 10.6).

463

and the

Contents of the Medial Fascial

Compartment of the Thigh

■

L2 L3 L4

femoral nerve

abdomen

lumbar plexus

iliacus

pectineus

hip joint

intermediate cutaneous
nerve of thigh
medial cutaneous
nerve of thigh

sartorius

quadriceps

femoris

knee joint

femoral artery

saphenous nerve

branch to subsartorial

plexus

infrapatellar

branch to skin

to skin of medial

side of leg

skin on medial

side of foot

as far as ball

of big toe

front
of
thigh

lower
leg

foot

FIGURE 10.28

Summary of the main branches of the femoral

nerve.

464

CHAPTER 10

The Lower Limb

Muscles of the Medial Fascial Compartment of the Thigh

T A B L E 1 0 . 3

Hamstring portion:

Adductor portion:

of shaft of femur,

Muscle

Origin

Insertion

Nerve Supply

Nerve Root

Action

Gracilis

Inferior ramus of pubis,

ramus of ischium

Upper part of shaft

of tibia on medial

surface

Obturator

nerve

L2, 3

Adducts thigh at hip

joint; flexes leg at

knee joint

Adductor longus

Body of pubis, medial to

pubic tubercle

Posterior surface

of shaft of femur

(linea aspera)

Obturator

nerve

L2, 3, 4

Adducts thigh at hip

joint and assists in

lateral rotation

Adductor brevis

Inferior ramus of pubis

Posterior surface

of shaft of femur

(linea aspera)

Obturator

nerve

L2, 3, 4

Adducts thigh at hip

joint and assists in

lateral rotation

Adductor magnus

Inferior ramus of pubis,

ramus of ischium,

ischial tuberosity

Posterior surface

adductor tubercle

of femur

obturator nerve

sciatic nerve

L2, 3, 4

Adducts thigh at hip

joint and assists

in lateral rotation;

hamstring portion

extends thigh at hip

joint

Obturator externus

Outer surface of obturator

membrane and pubic

and ischial rami

Medial surface of

greater trochanter

Obturator nerve

L3, 4

Laterally rotates thigh

at hip joint

The predominant nerve root supply is indicated by boldface type.

gluteus
maximus

semimembranosus

semitendinosus

genicular artery

adductor tubercle

semimembranosus

tibial nerve

popliteus

head of fibula

plantaris

common peroneal
nerve

short head

long head

biceps
femoris

sciatic nerve

linea aspera

biceps femoris

gluteus maximus

adductor magnus

gemellus superior

piriformis

gluteus minimus

gluteus medius

popliteal vein

popliteal artery
opening in
adductor magnus

quadratus femoris

greater trochanter

gemellus inferior

obturator internus

nerve to hamstrings

adductor magnus
(hamstring part)

FIGURE 10.29

Deep structures in the posterior aspect of the

(see page 256). It passes forward on the lateral wall of

The obturator artery is a branch of the internal iliac artery

Obturator Artery

to the branches of the artery. It drains into the femoral vein.

The profunda femoris vein receives tributaries that correspond

Profunda Femoris Vein

branches of the popliteal artery below.

the circumflex femoral arteries above and the muscular

one another and with the inferior gluteal artery and

supply the muscles and terminate by anastomosing with

ward, piercing the various muscle layers as they go. They

artery (Fig. 10.27). The perforating arteries run back

perforating artery is the terminal part of the profunda

branches of the profunda femoris artery; the fourth

Three of these arise as

Four perforating arteries:

the cruciate anastomosis.

muscles of the region and takes part in the formation of

(Fig. 10.6). It breaks up into branches that supply the

ally between the terminal branches of the femoral nerve

This passes later

Lateral femoral circumflex artery:

takes part in the formation of the cruciate anastomosis.

medial fascial compartment of the thigh (Fig. 10.27). It

femoral triangle and gives off muscular branches in the

ward between the muscles that form the floor of the

This passes back

Medial femoral circumflex artery:

Branches

artery (Fig. 10.27).

adductor magnus, where it ends as the fourth perforating

adductor longus and adductor brevis and then lies on the

10.24, and 10.26). It descends in the interval between the

about 1.5 in. (4 cm) below the inguinal ligament (Figs. 10.6,

right thigh.

■

Basic Anatomy

and passes downward behind the adductor brevis and in

pierces the obturator externus

posterior division

The

the thigh.

rial plexus and supplies the skin on the medial side of

artery. It contributes a variable branch to the subsarto

terminates as a small nerve that supplies the femoral

pectineus. It gives articular branches to the hip joint and

tor brevis, and adductor longus, and occasionally to the

10.30). It gives muscular branches to the gracilis, adduc

the pectineus and adductor longus (Figs. 10.27 and

obturator externus and the adductor brevis and behind

passes downward in front of the

anterior division

The

Branches

anterior and posterior divisions (Fig. 10.27).

obturator foramen (see Fig. 6.12), where it divides into

the lateral wall of the pelvis to reach the upper part of the

cle within the abdomen (see page 222). It runs forward on

and 4) and emerges on the medial border of the psoas mus

The obturator nerve arises from the lumbar plexus (L2, 3,

Compartment of the Thigh

Nerve Supply of the Medial Fascial

vein.

the branches of the artery. It drains into the internal iliac

The obturator vein receives tributaries that correspond to

Obturator Vein

branches and an articular branch to the hip joint.

surface of the obturator membrane. It gives off muscular

eral branches, which pass around the margin of the outer

compartment of the thigh, it divides into medial and lat

tor foramen) (Fig. 10.27). On entering the medial fascial

the obturator canal (i.e., the upper part of the obtura

the pelvis and accompanies the obturator nerve through

465

Obturator Nerve

■

front of the adductor magnus (Fig. 10.27). It terminates

by descending through the opening in the

adduct

tor brevis.

of the adductor magnus, and occasionally to the adduc

branches to the obturator externus, to the adductor part

magnus to supply the knee joint. It gives muscular

group of muscles and permits slow recovery of the muscles

crushed. This operation overcomes the spasm of the adductor

severe cases, the posterior division of the obturator nerve is

the anterior division of the obturator nerve. In addition, in some

form a tenotomy of the adductor longus tendon and to divide

In patients with cerebral palsy who have marked spasticity of

Adductor Muscles and Cerebral Palsy

the adductor group of muscles, it is common practice to per-

supplied by the posterior division of the obturator nerve.

C L I N I C A L N O T E S

The Back of the Thigh

in Figure 10.31 and are described in Table 10.4.

The muscles of the posterior fascial compartment are seen

Sciatic nerve

Nerve supply:

Branches of the profunda femoris artery

Blood supply:

string muscles)

nosus, and a small part of the adductor magnus (ham

Biceps femoris, semitendinosus, semimembra

Muscles:

group of superficial inguinal lymph nodes (Fig. 10.4).

of the thigh drains upward and forward into the vertical

Lymph from the skin and superficial fascia on the back

Lymph Vessels

vein in the popliteal fossa.

lower part of the back of the thigh join the small saphenous

saphenous vein (Fig. 10.19). Superficial veins from the

aspects of the thigh and ultimately drain into the great

Many small veins curve around the medial and lateral

Superficial Veins

(Fig. 10.1).

skin on the back of the thigh and the upper part of the leg

supplies the skin. It gives off numerous branches to the

and in the popliteal fossa it pierces the deep fascia and

muscle (Fig. 10.1). It descends on the back of the thigh,

from beneath the lower border of the gluteus maximus

the sacral plexus, leaves the gluteal region by emerging

a branch of

posterior cutaneous nerve of the thigh,

The

Cutaneous Nerves

Skin

Contents of the Posterior Fascial

Compartment of the Thigh

■

-
-

■

L2 L3 L4

obturator nerve

abdomen

lumbar plexus

pelvis

peritoneum on lateral
wall of pelvis

anterior division

posterior division

adductor
region
of thigh

hip joint

pectineus ?

adductor longus

adductor brevis

gracilis

adductor magnus

(adductor portion)
adductor brevis

knee joint

popliteal artery

femoral artery

subsartorial plexus

with medial cutaneous

nerve of thigh and branch

of saphenous nerve

FIGURE 10.30

Summary of the main branches of the obtura

tor nerve.